NURS 101L | Fundamentals of Nursing Skills Lab | Exam 2 Advanced
Study Guide 2026 |WCU
1. A nurse is preparing to perform a sterile dressing change. Which action by the
nurse would result in the immediate contamination of the sterile field?
A. Opening the first flap of the sterile kit away from the body.
B. Turning her back to the sterile field to grab a pair of clean gloves.
C. Placing a sterile gauze pad within the 1-inch border of the sterile field.
D. Holding sterile forceps above the level of the waist.
Answer: B
Rationale: A sterile field is considered contaminated if it is out of the range of vision or if
the nurse turns their back on the field. The 1-inch border is already considered
contaminated, but turning away is a more fundamental breach of asepsis.
2. When administering a 0.5 mL intramuscular injection to a 6-month-old infant,
which site is the most appropriate for the nurse to select?
A. Dorsogluteal
B. Vastus lateralis
C. Deltoid
D. Ventrogluteal
Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in infants under 12
months because it is the most developed muscle and lacks major nerves or blood vessels.
,3. The nurse is assessing a patient’s intravenous (IV) site and notes coolness,
pallor, and significant swelling around the insertion point. What is the nurse’s
priority action?
A. Apply a warm compress to the site immediately.
B. Flush the IV with 10 mL of normal saline to check patency.
C. Slow the infusion rate to keep the vein open.
D. Stop the infusion and discontinue the IV catheter.
Answer: D
Rationale: The symptoms describe IV infiltration. The priority action is to stop the infusion
and remove the catheter to prevent further tissue damage before implementing comfort
measures like elevation or compresses.
4. While inserting a nasogastric (NG) tube, the patient begins to cough, gag, and
shows signs of respiratory distress. Which action should the nurse take first?
A. Advance the tube quickly to reach the stomach.
B. Withdraw the tube slightly and wait for the patient to recover.
C. Remove the tube completely and assess oxygen saturation.
D. Pause and ask the patient to take small sips of water.
Answer: C
Rationale: Signs of respiratory distress during NG insertion suggest the tube has entered
the airway. The nurse must remove the tube immediately to ensure the airway is clear.
5. A patient requires a ‘Z-track’ injection of iron dextran. What is the primary
purpose of using the Z-track technique?
A. To ensure the medication enters the subcutaneous tissue.
B. To increase the speed of medication absorption.
C. To decrease the pain associated with a large volume of fluid.
D. To prevent the medication from leaking into the subcutaneous tissue and causing irritation.
Answer: D
, Rationale: The Z-track method seals the medication within the muscle layer and prevents
it from tracking back through the needle path into sensitive subcutaneous tissues, which
reduces irritation and staining.
6. Which of the following is the most reliable method for confirming the initial
placement of a nasogastric (NG) tube after insertion?
A. Aspirating gastric contents and checking the pH.
B. Auscultating an air bolus over the epigastrium.
C. Obtaining a chest/abdominal X-ray.
D. Observing the patient for the absence of coughing.
Answer: C
Rationale: X-ray visualization is the gold standard and most reliable method for
confirming NG tube placement before any feedings or medications are administered.
7. The nurse is preparing to administer an intradermal injection for a tuberculin
skin test. At what angle should the needle be inserted?
A. 90 degrees
B. 45 degrees
C. 5 to 15 degrees
D. 30 degrees
Answer: C
Rationale: Intradermal injections are administered into the dermis, just under the
epidermis, at a shallow angle of 5 to 15 degrees with the bevel up.
Study Guide 2026 |WCU
1. A nurse is preparing to perform a sterile dressing change. Which action by the
nurse would result in the immediate contamination of the sterile field?
A. Opening the first flap of the sterile kit away from the body.
B. Turning her back to the sterile field to grab a pair of clean gloves.
C. Placing a sterile gauze pad within the 1-inch border of the sterile field.
D. Holding sterile forceps above the level of the waist.
Answer: B
Rationale: A sterile field is considered contaminated if it is out of the range of vision or if
the nurse turns their back on the field. The 1-inch border is already considered
contaminated, but turning away is a more fundamental breach of asepsis.
2. When administering a 0.5 mL intramuscular injection to a 6-month-old infant,
which site is the most appropriate for the nurse to select?
A. Dorsogluteal
B. Vastus lateralis
C. Deltoid
D. Ventrogluteal
Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in infants under 12
months because it is the most developed muscle and lacks major nerves or blood vessels.
,3. The nurse is assessing a patient’s intravenous (IV) site and notes coolness,
pallor, and significant swelling around the insertion point. What is the nurse’s
priority action?
A. Apply a warm compress to the site immediately.
B. Flush the IV with 10 mL of normal saline to check patency.
C. Slow the infusion rate to keep the vein open.
D. Stop the infusion and discontinue the IV catheter.
Answer: D
Rationale: The symptoms describe IV infiltration. The priority action is to stop the infusion
and remove the catheter to prevent further tissue damage before implementing comfort
measures like elevation or compresses.
4. While inserting a nasogastric (NG) tube, the patient begins to cough, gag, and
shows signs of respiratory distress. Which action should the nurse take first?
A. Advance the tube quickly to reach the stomach.
B. Withdraw the tube slightly and wait for the patient to recover.
C. Remove the tube completely and assess oxygen saturation.
D. Pause and ask the patient to take small sips of water.
Answer: C
Rationale: Signs of respiratory distress during NG insertion suggest the tube has entered
the airway. The nurse must remove the tube immediately to ensure the airway is clear.
5. A patient requires a ‘Z-track’ injection of iron dextran. What is the primary
purpose of using the Z-track technique?
A. To ensure the medication enters the subcutaneous tissue.
B. To increase the speed of medication absorption.
C. To decrease the pain associated with a large volume of fluid.
D. To prevent the medication from leaking into the subcutaneous tissue and causing irritation.
Answer: D
, Rationale: The Z-track method seals the medication within the muscle layer and prevents
it from tracking back through the needle path into sensitive subcutaneous tissues, which
reduces irritation and staining.
6. Which of the following is the most reliable method for confirming the initial
placement of a nasogastric (NG) tube after insertion?
A. Aspirating gastric contents and checking the pH.
B. Auscultating an air bolus over the epigastrium.
C. Obtaining a chest/abdominal X-ray.
D. Observing the patient for the absence of coughing.
Answer: C
Rationale: X-ray visualization is the gold standard and most reliable method for
confirming NG tube placement before any feedings or medications are administered.
7. The nurse is preparing to administer an intradermal injection for a tuberculin
skin test. At what angle should the needle be inserted?
A. 90 degrees
B. 45 degrees
C. 5 to 15 degrees
D. 30 degrees
Answer: C
Rationale: Intradermal injections are administered into the dermis, just under the
epidermis, at a shallow angle of 5 to 15 degrees with the bevel up.
